By right or by policy

The opposition has called Ayushman Bharat – the flagship healthcare programme of the Narendra Modi government – a life-saver for the private sector, rather than for the poor. The hospital insurance component of the programme, namely Pradhan Mantri Jan Aarogya Yojana (PMJAY), envisages extensive partnership with the private sector, from healthcare provisioning to insurance administration and from private hospitals to third party administrators (TPA). In response, Congress has promised in its election manifesto a ‘Right to Healthcare Act’, based on increasing public health spending to 3% of GDP and strengthening the public health infrastructure.

A problematic model of private public partnership envisaged under PMJAY makes it vulnerable to allegations of unduly favouring the private sector. The NITI Aayog’s PPP guidelines on non-communicable disease (NCD) management – which invites private partners to build and run NCD units in certain district hospitals – allows for encroachment by the private sector on an already ramshackle public healthcare sector, further chipping away at the State’s negotiating power. Also, the government has invited the private sector to open hospitals in tier 2 and 3 cities in return for generous incentives, while doing little to shield public hospitals in these areas and keep them in competition.

As these measures aim to expand access to care under PMJAY, diverting public investment from public hospitals to the private sector entails an increasing circumscription of the scope of public healthcare to a limited segment of the population, while private health spending caters to the rest. This is an unpromising model for a country where nearly three-fourths of the population belong to low income category. Not to count the huge public inflows to private insurance companies and TPAs by way of administrative expenses of PMJAY.

Furthermore, ‘Modicare’ hasn’t hitherto offered reassuring signals with respect to strengthening the general primary healthcare infrastructure –- the backbone of any system of universal healthcare. The aim of building 1.5 Lakh functional health and wellness centres by 2022, announced as part of Ayushman Bharat, appears to lack a solid roadmap, with a sub-textual preferential emphasis on the hospital insurance component, the PMJAY. The National Health Mission also remains impervious to substantial budgetary increases year after year.

A formidable challenge

The idea of a ‘Right to Healthcare Act’, proposed by the Congress, which basically would make healthcare a justiciable right of citizens, comes against an intriguing background. The National Health Policy (NHP), 2017, compiled after extensive consultations with a diverse group of stakeholders, noted that a “Right to health cannot be perceived unless the basic health infrastructure like doctor-patient ratio, patient-bed ratio, nurses-patient ratio, etc., are near or above threshold levels and uniformly spread-out across the geographical frontiers of the country”, and instead recommended “a progressive incremental assurance-based approach” until an enabling environment for realizing health as a right is achieved.

With a doctor-population ratio of 1:1,681; one government hospital bed for 2,000 population, and a shortage of 6,430 primary health centres and 32,900 sub-health centres, guaranteeing even the minimum basic entitlements for all will require massive investments in public health infrastructure and manpower. Furthermore, it will require addressing multiple, entrenched imbalances in the health ecosystem: regional disparities of health facilities and manpower; medical versus paramedical staff; curative versus preventive healthcare –- along with the larger questions of ineffectual decentralization, reigning in of private and informal providers, and installing a primary care gatekeeper.

Such an overhaul is a matter of gradual and progressive realization over many years, rather than an immediate undertaking, and will require consistently high levels of political will, which even the party in question has failed to demonstrate convincingly in its previous tenure. In 2005, the year the National Rural Health Mission was rolled out, the then prime minister in a speech delivered at AIIMS, New Delhi, had recognized health as an inalienable human right. Still, the health spending refused to cross the 1% of GDP mark till the end of his tenure in 2014, despite promises of spending up to 2.5%. The high-level expert group on universal health coverage, 2011 recommendations of increasing spending to 2.5% of GDP till 2017 and increasing functional bed capacity to 2 per 1,000 by 2022 (existing around 0.9 per 1,000) were paid little attention to.

A law can only be as good as its enforcement, and here there are two key elements: political commitment, and public awareness and pressure. In the absence of either, a law can suffer from weak implementation, as with the already existing clinical establishments laws meant to regulate healthcare establishments in the country.

The world over, right to health has mostly been realized as a result of strong civic awareness and activism mobilizing political action to enforce the same. Under international instruments like the International Covenant of Economic, Social, and Cultural Rights and Article 21 of the Indian Constitution, a legal responsibility already exists on the Indian State to commit substantial resources to public health, but these hardly get invoked. Nonetheless, an explicit legislation can be of great help –- by not just creating a binding legal obligation for the State to guarantee essential healthcare entitlements, but also by raising public awareness about the human rights paradigm of health.

A survey by the Association for Democratic Reforms has shown that health ranks second only to employment concerns for the public, which points at a good degree of felt need for affordable healthcare. However, translation of this felt need into a vigorous public demand for services has been incomplete. Whatever be the approach – rights-based or policy-driven – strong public pressure for action will be instrumental in transforming healthcare in the country.

(The writer is Chief Editor, The Indian Practitioner, and a medical doctor based in Mumbai)